PECOS Problems Mount, but So Far No Delay

ATLANTA — Doctors’ offices are complaining about the
burdens of registering in CMS’ Provider Enrollment, Chain and
Ownership System (PECOS), with many reporting log-in problems, long
telephone waits for help and numerous Web pages to be filled out.
But the clock is ticking toward the Jan. 4, 2010, deadline when
Medicare will stop paying claims from HME providers unless the
ordering physician is registered in the system.

There has been no word on a deadline delay, although an
estimated 200,000 Medicare physicians and other health care
practitioners still need to enroll as the remaining time
dwindles.

On Monday (Nov. 16), the American Medical Association and 56
other physician and clinical associations sent a strongly worded
letter to Charlene Frizzera, acting administrator for CMS, about
the situation. The letter states: “Implementing this policy as
scheduled will cut off access to care for millions of Medicare
beneficiaries, interrupt reimbursement for legitimately provided
items and services, interrupt care coordination, and add unfunded
administrative mandates on a significant portion of physicians and
other health care practitioners.”

The letter recommends “indefinitely” suspending implementation
of the plan to reject claims and “waiting at least until all
practicing Medicare physicians … can be revalidated and
reenrolled or enrolled for the first time.” The physicians also
asked that CMS take action to “ensure that otherwise acceptable
claims are paid without delay or need for appeals.” (See Docs Ask for PECOS Delay,
Nov. 17.)

No new information on the PECOS was given during a Tuesday
afternoon Open Door call for physicians. CMS reiterated its intent,
previously announced on Oct. 30, to populate existing PECOS
enrollment records with missing NPI numbers for physicians, and to
make available a national file of practitioners who are eligible to
order/refer.

But the problem with that, according to stakeholders, is that
the file and the updated database may not be available until
mid-December, giving providers only a couple of weeks to use the
tools before the claim rejection date.

“It’s a good thing they are going to provide the listing [file],
but it will be a day late and a dollar short because there will
only be a few weeks until the payments stop,” said John Shirvinsky,
executive director of the Pennsylvania Association of Medical
Suppliers. “What has to govern CMS at this point is to make sure
they do this right, not do it fast. They may have to extend the
deadline. I think they are trying to get a handle on who’s in the
system [by populating the NPI numbers].”

Providers began to receive CEDI warnings on claims processed on
or after Oct. 5 based on an expanded editing process that
cross-matches a claim’s ordering physician/practitioner against
PECOS enrollment. Unmatched claims will be rejected beginning in
January.

The AMA letter states the new policy was “quietly announced,”
and providers have confirmed that many of their referral sources
were unaware of the PECOS.

Shirvinsky suggested that the strategy among HME companies is
likely to change from trying to educate doctors to reaching out to
patients to let them know their options. It would be reasonable for
a patient to expect at least a 30-day notification of Medicare
payments ending, he said, which would require providers to start
making those notifications in early December. “The options for
providers have been taken away,” said Shirvinsky.

Some members of PAMS have seen a recent decrease in the
percentage of claims that receive CEDI warnings, but others have
seen an increase; reports range from warnings on 10 percent to 40
percent to 60 percent. “The system is nowhere near ready to roll
out,” Shirvinsky said. He speculated that some physician offices
are hesitant to amend or update the information they have supplied
to Medicare on the fear that they will make a mistake that could
put their own Medicare status in jeopardy.

“It’s an ongoing crisis, and there is a lot of confusion,” he
said. “We have received calls from physicians who have tried to
register. The process is all bollixed up. The concern is that if
there is a comma in the wrong place, something not written in all
caps, and all of a sudden you lose your ability to participate in
Medicare.”

The American Association for Homecare also has drafted a letter
to Frizzera stating that the timing of the new policy and resulting
denial of clams will have a harmful effect on both providers and
beneficiaries. “We don’t see any way of getting around this without
a lengthy delay because the education level of physicians is low,
and it’s cumbersome to apply because physicians don’t have any skin
in the game,” said the association’s Walt Gorski, vice president,
government relations.

In a meeting with CMS officials about the problems earlier this
month, Gorski said, “CMS was not ready or willing to commit to a
delay … Clearly, CMS is finding out the problem [with
physician registration] is probably worse than they
anticipated.”

Physicians Frustrated, Too

Meanwhile, physician office horror stories of trying to interact
with the PECOS are common.

“I just had a call from a woman in a physician’s office who said
she had been on the phone for two-and-a-half hours waiting to ask
about her doctor’s information in PECOS,” said Joan Cross,
executive director of the Florida Association of Medical Equipment
Services. “When she finally got someone to talk to, she said she
was told the physician himself would have to call in. ‘Do they want
him to sit on the phone for two-and-a-half hours?’ the woman asked
me.”

Kevin Fly Hill, president of CPS Medical, Tyler, Texas,
recounted contacting the employee responsible for certifications
and paperwork at a large education-based health care system that
supports more than 100 doctors.

“As I queried her about PECOS and the potential of problems
related to physicians not being properly registered, she assured me
that she had all of her information and paperwork up to date,” Hill
said. But after Hill faxed her a copy of the warnings he had
received, she called back. It turns out her doctors were not
properly registered and she would “have her hands full for the next
week” getting everything done.

Hill said she added: “When I reread my notices from Medicare/CMS
they had not stressed the importance or really the need to do this
process, but there it was. I don’t know whether to hug you or hit
you, but I need to get busy and make sure these get processed
before the end of the year!”

Hill said it may take as long as four to six weeks “for
processing the paperwork that you must download, print, fill out,
have signed by the doctor and mail to the carrier for Medicare. Can
you imagine the backlog of work this will create when tens of
thousands of physicians’ paperwork shows up at the various Medicare
carriers who will have to physically input all of this information
into their systems? That was three weeks ago.”

Chris Rice, director of marketing for Diamond Respiratory Care,
Riverside, Calif., has created a Web site — www.getpecos.com
— to help educate physicians and others about PECOS.

“After speaking with physicians, we found that there was no
simple way for them to take action,” said Rice. “Finding the
pertinent information on CMS’ site is difficult, and asking our
staff to explain how to find it was nearly impossible. We needed to
put all the CMS information in an easy-to-read format in one place
with an easy Web name to remember.”

The majority of the site’s content is taken from CMS bulletins,
but it is presented simply and using separate menu items. There are
also PDF files of CMS application instructions and screen shots of
the PECOS. “It’s disheartening to learn that the actual PECOS
system is difficult for physicians to navigate,” Rice said. “It has
over 44 screens.”

Leslie Zinn, office manager of Texas DME, Cleburne, Texas,
pointed out another problem. “In Texas, if a client has Medicare,
private insurance and Medicaid, and receives a product that is not
a covered Medicare benefit, it still must be billed to Medicare
first, then private insurance and then Medicaid. If a physician is
not entered in the PECOS system, the claim cannot be processed by
Medicare, and therefore cannot be sent to private insurance, and in
turn, cannot be sent to Texas Medicaid.”

The AMA letter estimates that as many as 200,000 Medicare
physicians and other health care practitioners are not in PECOS and
will need to re-enroll. According to the letter, one Medicare
contractor “reported 300,000 warning edits were issued the first
day of the [Phase 1] policy.” The letter also notes that only
electronic claims are receiving warnings; paper claims will just
stop being paid in January with no effective warning.

“The downstream providers and suppliers … are at risk of
nonpayment, even though they are not responsible for the
enrollment/reenrollment [process],” the letter states.

“It is impractical to require potentially hundreds of thousands
of physicians and other health care practitioners to reenroll …
by the end of 2009,” according to the physician groups. “Medicare
enrollment is widely regarded by the physician community as
extremely burdensome. We do not believe the new policy to be
consistent with [CMS] statutory authority, nor is it an effective
or appropriate approach to achieve [the] desired goal.”

According to a CMS representative who spoke during the Open
Door, there will be more information on the PECOS coming in a new
MLN Matters article, which she said should be posted on the CMS Web
site within two weeks.